2. CONTENTS
INTRODUCTION
CLASSIFIACTION
SUPRASTERNAL SPACE
PRIMARY FASCIAL SPACE
- RELATED TO UPPER JAW
- RELATED TO LOWER JAW
SECONDARY FASCIAL SPACE
LIFE THREATENING COMPLICATIONS
CONCLUSION
REFERENCE
3. INTRODUCTION
Soft tissue infections of head and neck are commonly
encountered in routine practice of oral and maxillofacial surgery,
In case of infection the classic signs and symptoms—pain,
swelling, surface erythema, lymphadenopathy, and systemically-
fever, malaise, toxic appearance, and an elevated white blood
cellcount is present
DEFINITION
Shapiro defined fascial spaces as potential spaces between the
layer of fascia. These spaces are normally filled with loose
connective tissues and various structures like veins, arteries,
glands, lymph nodes, etc.
4. CLASSIFICATION OF FASCIAL
SPACE
BASED ON CLINICAL SIGNIFICANCE
Primary maxillary spaces
Canine (infraorbital)
Buccal
Infratemporal
Primary mandibular spaces
Submental
Submandibular
Sublingual
Buccal
5. Secondary fascial spaces
Masseteric
Pterygomandibular
Superficial and deep temporal
Lateral pharyngeal
Retropharyngeal
Prevertebral
7. GRODINSKY & HOLYOKE CLASSIFICATION
Space 1 : potential space superficial & deep to platysma muscle
Space 2 : space behind the anterior layer of deep cervical fascia
Space 3 : pretracheal space lies anterior to trachea
Space 3 A : viscera vascular space( lincolns highway as coined by
Mosher)
Space 4 : Danger area b/w alar & prevertebral fascia
8. BASED ON MODE OF INVOLVEMENT
Direct involvement:
Primary spaces
1. Maxillary spaces
2. Mandibular spaces
Indirect involvement:
Secondary spaces
10. SUPRASTERNAL SPACE( OF BURNS)
The suprasternal space (of Burns) is a space of the inferior
neck. Superficial fascia splits below the level of the hyoid
bone to form two spaces:
1. It forms the lower part of the root of the posterior triangle, the
fascia splits into two layers, both of which are attached to the
clavicle.
2. It forms the lower part of the roof of the anterior triangle and
the fascia splits in form the suprasternal space or the space of
the ‘burns’.
11. CONTENTS
Sternal head of sternocleidomastoid muscle
Anterior Jugular vein anastomoses
Lymph nodes
Interclavicular ligament
12. PRIMARY FASCIAL SPACES
SPACES RELATED TO UPPER JAW
CANINE SPACE
ETIOLOGY: Odontogenic infection
nasal infection, less frequent
BOUNDARIES:
Superficial and superior—Quadratus labii superioris
Inferior—Orbicularis oris
Deep—Levator anguli oris, anterior surface of maxilla
Medial—Levator labii superioris alaeque nasi
Lateral—Zygomaticus major
13. CONTENT:
Angular artery and vein
Infraorbital nerve
TEETH INVOLVED
Maxillary canine, 1st premolar infection and sometimes mesiobuccal root of first
molars
CLINICAL FEATURES
• Periapical abscess of canine usually present as labial sulcus swelling
and less commonly as palatal swelling
• Swelling of the cheek and upper lip (vestibular abscess)
• Obliteration of the nasolabial fold
• Oedema of the lower eyelid.
• Marked periorbital oedema forcing the eyelid to close.
• Marked tenderness and redness in the facial tissue.
14. SURGICAL MANAGEMENT
The incision is made intraorally high in the maxillary labial
vestibule.
Insert a small haemostat through the levator anguli oris into the
abscess cavity
place a rubber drain and suture into the lower margin of the
vestibular incision.
15. BUCCAL SPACE
BOUNDARIES
Superior—Zygomatic arch
Inferior—Inferior border of mandible
Anterior—Posterior border of the zygomatic bone above and
depressor angulioris below
Posterior—Anterior border of the masseter muscle
Medial—Buccinator muscle and its fascia
Lateral—Skin and subcutaneous tissue.
16. CONTENTS
Space filled with buccal pad of fat (adipose tissues)
Parotid duct
Anterior and transverse facial artery and vein.
TEETH INVOLVED
Maxillary and mandibular premolars and molars.
CLINICAL FEATURES
-Pus acumination leads to gum boil seen in vestibule
-Prominent extra oral swelling
-swelling extending from lower border of mandible to infraorbital
margin & from anterior margin of masseter to corner of mouth.
-Edema of lower eyelid.
17. SURGICAL MANAGEMENT
Horizontal incision through the oral mucosa of the cheek in the
premolar molar region
If the pus is lateral to the muscle, then the muscle is penetrated
with curved mosquito forceps to enter the buccal space
Drain is placed & secured with suture
18. INFRATEMPORAL SPACE
Also called as retrozygomatic space as it is partly situated behind the
zygomatic bone
BOUNDARIES
Superior—Skull base-sphenoid crest
Inferior—Lateral pterygoid muscle
Medial—Lateral pterygoid plate
Lateral—Temporalis muscle and tendon
Anterior—Maxillary tuberosity
Posterior—Mandibular condyle
19. CONTENTS
-Internal maxillary artery (second part)
- Pterygoid venous plexus
-Mandibular division of trigeminal nerve
-Medial and lateral pterygoid muscles
INVOLVEMENT
Infratemporal fossa may also become secondarily infected from
infections of the submasseteric, parotid and lateral pharyngeal
spaces.
20. CLINICAL FEATURES
EXTRA ORAL- trimus
- bulging of temporalis muscle
- marked swelling of the face
- eye is closed & often proptosed
INTRAORAL – swelling in the tuberosity zone
21. SURGICAL MANAGEMENT
Infratemporal space can be reached either intraorally or extraorally.
-Internal approach (Kruger) consists of an incision made in the
buccolabial fold lateral to the maxillary third molar.
-A curved haemostat is introduced carefully behind the tuberosity of
the maxilla and directed medially andsuperiorly within the cavity.
-A drain is then inserted.
-According to Laskin, a vertical incision is made medial to the upper
extentof the anterior border of ramus of the mandible.
- A haemostat is introduced and passed superiorly into the
infratemporal region and a drain is introduced.
22. SPACES RELATED TO LOWER JAW
SUBMENTAL SPACE
BOUNDARIES
Superior—Mylohyoid muscle
Inferior—Skin and subcutaneous tissue, platysma and deep cervical
fascia
Medial—Single midline space with no medial wall
Lateral—Anterior belly of digastric (bilateral)
Anterior—Mandible
Posterior—Hyoid bone
23. CONTENTS
no vital structures
Lymph nodes and anterior jugular veins
INVOLVEMENT
Infection from lower incisors, lower lip, chin, tip of the tongue and
anterior part of floor of the mouth
CLINICAL FEATURE
Extraoral findings- Distinct,
-firm swelling in midline,beneath the chin.
-Skin overlying the swelling is board-like and taut.
- Fluctuation may be present.
24. Intraoral findings: The anterior teeth are either nonvital, fractured or
carious.
The offending tooth may exhibit tenderness to percussion and may
showmobility.
The patient may experience considerable discomfort on swallowing.
SURGICAL MANAGEMENT
-The incision for drainage is made bilaterally through the skin,
subcutaneous tissue and platysma muscle at the most inferior aspect
of the swelling.
-Rubber drain is inserted through one incision, exited through the
other and secured with the help of sutures and dressing applied
25. SUBMANDIBULAR SPACE
BOUNDARIES
Lateral—Skin, superficial fascia, investing fascia, platysma
Medial—Mylohyoid, hyoglossus, superior constrictor, styloglossus
muscles
Superior—Inferior and medial surface of the mandible and attachment of mylohyoid
muscle
Inferior—Anterior and posterior belly of digastrics muscle
26. CONTENTS
-Submandibular salivary gland and lymph nodes
- Facial artery
- Lingual nerve
-Lymph nodes
INVOLVEMENT
-Infection from the mandibular molars, most commonly second and
third molar
-Infection from submental and sublingual spaces
-Infection from the submandibular salivary gland
-Infection from the middle third of the tongue, posterior part of the floor
of the mouth, maxillary teeth, cheek, maxillary sinus and palate
27. CLINICAL FEATURE
Extraoral:
- Firm swelling in submandibular region,below the inferior border of mandible,
- generalizedconstitutional symptoms.
-some degree oftenderness,
- redness of overlying skin.
Intraoral:
-Teeth are sensitive to percussion
Teeth are mobile
-dysphagia
-moderate trismus.
28. SURGICAL MANAGEMENT
-Two stab incisions are made at the inferior aspect of the swelling in
the shadow of the mandible.
-The dissection is carried out through one of the incisions with the
curved haemostat in the abscess cavity.
-Blunt dissection avoids the risk of injuring the facial artery, anterior
facial vein and facial nerve.
-The haemostat is passed through one incision and out through the
other.
-A thin rubber drain is passed through the stab incisions with the help
of the haemostat.
-The ends of the drain are sutured to prevent dislodgement.
30. CONTENTS:
-Deep part of submandibular gland, sublingual gland and their
draining ducts (Wharton’s duct and ducts of Rivinus)
-Lingual nerve
CLINICAL FEATURE:
Extraoral:
- There is little or no swelling.
-The lymnhnodes may be enlarged and tender.
- Pain and discomfoon deglutition.
- Speech may be affected.
31. Intraoral:
Firm, painful swelling seen in the floor of themouth on the affected side.
-The floor of the mouth is raised.
-The tongue may be pushed superiorly.
-airway obstruction.
-The ability to protrudethe tongue beyond the vermillion border of upper
lip is affected.
SURGICAL MANAGEMENT:
Drainage of the abscess is obtained through
Extra oral approach—an external transverse skin incision between the
hyoid bone and the inferior border of the mandible.
32. Intra oral approach—Drainage can be obtained transorally by incising
the mucosa in the anterior part of the floor of the mouth, the incision
should be placed parallel to the submandibular duct.
Blunt dissection is indicated so as to not injure the lingual nerve or the
submandibular gland
33. SECONDARY FASCIAL SPACES
TEMPORAL SPACE
Temporal space has two compartments: superficial and deep.
BOUNDARIES:
Superficial compartment:
Laterally—Temporal fascia
Medially—Lateral surface of the temporalis muscle
Deep compartment:
Laterally—Medial surface of the temporalis muscle
Medially—Temporal bone
34. CONTENTS:
Superficial temporal vessels, auriculotemporal nerve and temporal fat
pad.
CLINICAL FEATURE:
- Pain and swelling
- Swelling over the temporal region
SURGICAL MANAGEMENT:
-extra oral incirion in temporal region, above hairline 45 degree to
zygomatic arch
-hemostat is entered above & below the temporalis muscle
35. PAROTID SPACE
Parotid space is enclosed by the superficial layer of the deep
cervical fascia surrounding the parotid gland.
BOUNDARIES
-Space is formed by splitting of superficial layer of deep cervical
fascia surrounding parotid gland
- lies posterior to masticatory space.
Inferiorly : stylomandibular ligament separates parotid from
mandibular space.
CONTENTS:
-parotid gland &lymph nodes
-facial nerve
-retromandibular vein
-external carotid artery
36. CLINICAL FEATURE:
-Swelling.
Swelling everts the lobule of the ear and presents with severe pain
especially while eating.
-Intraorally pus may be milked from the parotid duct.
MANAGEMENT
-Large incision is made in the retromandibular area from lower aspect
of lobule of the ear to angle of the mandible.
-Blunt dissection with a haemostat is done avoiding injury to the
branches of the facial nerve.
-Multiple drains are used for drainage of the pus.
-A curved incision at the angle of the mandible can also be made;
blunt dissection is done with a haemostat and a drain is placed.
37. SUBMASSETERIC SPACE
BOUNDARIES:
Anterior—Buccal space, parotidomasseteric fascia
Posterior—Parotid gland and its fascia
Superior—Zygomatic arch
Inferior—Inferior border of mandible
Superficial or medial—Ascending ramus
Deep or lateral—Masseter muscle
CONTENTS
Masseteric artery & vein
38. CLINICAL FEATURE:
-Extraorally, the swelling is seen mainly over the angle of the
mandible.
-severe trismus and throbbing pain
-Chronic submasseteric space infection can be punctuated by
recurrent exacerbation
-subperiosteal new bone deposition beneath the periosteum, an
important clue to the diagnosis.
39. SURGICAL MANAGEMENT
-A vertical incision is made intraorally along the external oblique line of
the mandible.
-A haemostat is inserted through this incision and passed posteriorly
along the lateral aspect of the ramus beneath the masseter muscle and
the beaks are opened for free escape of the pus.
-A rubber drain is inserted and sutured to the incision margin.
-Extraoral approach involves a small incision beneath the angle of the
mandible and blunt dissection is done with the help of the haemostat.
- A rubber catheter is inserted in the wound for drainage
40. PTERYGOMANDIBULAR SPACE
BOUNDARY:
Anterior—Buccal space
Posterior—Parotid gland with lateral pharyngeal space
Superior—Lateral pterygoid muscle Inferior—Inferior border of
mandible
Superficial or medial—Lateral surface of medial pterygoid muscle
Deep or lateral—Medial surface of ascending ramus of mandible
41. CLINICAL FEATURE
-Extraorally swelling
-Intraorally, there is visible swelling of the soft palate on the same
side
-swelling of the anterior tonsillar pillar
-deviation of the uvula to the opposite side
-severe trismus and dysphagia.
42. SURGICAL MANAGEMENT
-The incision for drainage is made between medial aspect of the
ramus of mandible and the pterygomandibular raphe,
-the abscess cavity is opened by blunt dissection using a haemostat.
-Rubber drain is placed and sutured to one of the margins of the
incision to prevent dislodgement.
-This would help in sufficientdrainage.
43. LATERAL PHARYNGEAL SPACE
BOUNDARIES:
Anterior—Superior and middle pharyngeal constrictor
Posterior—Carotid sheath, stylohyoid, styloglossus and
stylopharyngeus
Superior—Skull base
Inferior—Hyoid bone
Superficial or medial—Superior pharyngeal constrictors and
retropharyngeal space
Deep or lateral—Medial pterygoid muscle and capsule of parotid
gland
44. CLINICAL FEATURE
-Severe pain on the affected side of throat and dysphagia are present
-tonsil, tonsillar pillar and uvula are displaced to the medial side.
-The four cardinal signs of lateral pharyngeal abscess are trismus, induration
and swelling of angle of the jaw, fever and pharyngeal bulging.
-Rotation of the neck away from the side of the swelling causes severe pain
-Complications of lateral pharyngeal abscess include septic jugular thrombophlebitis
and carotid artery erosion.
-Inequality of the pupils due to involvement of cervical sympathetic and
bleeding from nose, mouth or ear can be a warning of such a disastrous sequel.
-infections have a potential to spread upwards causing cavernous sinus
thrombosis, meningitis and brain abscess.
-They can also spread into theretropharyngeal space.
45. SURGICAL MANAGEMENT
-intraoral,extraoral and a combination of both.
-Intraoral incision can be either transpharyngeal or lateral. The
transpharyngeal approach is made through the tonsillar fossa,
-Extraoral submandibular incision is the safest approach and should be
used if there is any involvement of posterior compartments.
-In the combined intraoral and extraoral approach, the lateral mucosal
incision is made and a large curved haemostat is passed lateral to the
superior constrictor and medial to the medial pterygoid muscle.
A blunt dissection is carried out posteroinferiorly below the angle of the
mandible.
46. RETROPHARYNGEAL SPACE
BOUNDARIES:
Anterior—Superior and middle constrictors
Posterior—Alar fascia
Superior—Skull base
Inferior—Fusion of alar and prevertebral fascia at T4
Superficial or medial—Common space, no wall
Deep or lateral—Carotid sheath and lateral pharyngeal space
CONTENTS:
Lymph node, no major structures
47. CLINICAL FEATURES:
-symptoms include pain, fever, stiffness of the neck, dyspnoea,
drooling and dysphagia.
-Bulging of the posterior pharyngeal wall
- Retropharyngeal abscess is considered the most dangerous deep
neck space abscess, because complications include supraglottic
oedema with airway obstruction, aspiration pneumonia due to
rupture of the abscess and acute mediastinitis.
48. MANAGEMENT
-an intraoral approach is made.
-A vertical incision is made on the pharyngeal wall lateral to the
midline.
- Using a haemostat, abscess cavity is opened by blunt dissection
while the patient is in Trendelenburg position to avoid aspiration of
the pus.
-In case of concern about the rupture of the abscess, extraoral
approach is used for drainage.
49. PERITONSILLAR ABSCESS ( QUINSY)
-Peritonsillar abscess or quinsy is a deep neck infection usually
secondary to contiguous spread from the local sites or as a
complication of acute tonsillitis
-rarely life threatening in itself
CLINICAL FEATURE
-The infection is characterised by swelling of the tonsils
-uvular displacement
-trismus and muffled voice.
-Quinsy is usually unilateral
-Most abscesses occur in younger patients who present
with fever, sore throat and dysphagia
50. COMPLICATIONS
Spontaneous rupture and aspiration, contiguous spread to
pterygomaxillary space.
SURGICAL MANAGEMENT
If the patient is not seen until the pus is formed or if the antibiotic
therapy fails, the abscess must be drained.
But since peritonsillar abscess often tends to recur, tonsillectomy
should be performed 6–8 weeks after formation of the abscess.
51. LIFE THREATEMNING
COMPLICATIONS
RELATED TO LOWER JAW
-lugwigs angina
-descending deep cellulitis of neck, resulting in mediastinitis
-carotid sheath invasion
RELATED TO UPPER JAW
-Cavernous sinus thrombosis, brain abscess, dural meningitis &
osteomyelitis of skull
-retrobulbar cellulitis with possibility of blindness
52. CONCLUSION
Infection of orofacial region & neck have one of the most
common disease in human being
Despite great advancement in the healthcare , these infection
remains a major problem
These infection range from periapical abscess to superficial &
deep abscess of neck
Early recoginition and prompt appropriate treatment is
absolutely essential
53. REFRENCE
Neelima anil malik; text book of oral & maxillofacial
surgery:5th edition
S M Bhalaji;textbook of oral & maxillofacial surgery; 3rd
edition
